Views & Reviews Outside the Box

Exit the tie

BMJ 2009; 338 doi: (Published 20 May 2009) Cite this as: BMJ 2009;338:b2047
  1. Trisha Greenhalgh, professor of primary health care, University College London
  1. p.greenhalgh{at}

    The other day I had a call from St Cuthbert’s prep school. “Come quickly, doctor, Soames has collapsed.” I rushed round to find the spluttering boy on the floor of the dormitory. From his purple face and distended jugular veins, the diagnosis was clear: overtightened school tie syndrome.

    Stopping only to capture the scene on my iPhone to illustrate an article I was planning to submit to Cases journal, I pulled out my scalpel, and with a single swift movement I released the constricting knot and performed an emergency tracheostomy (just in case).

    As I tied the outer shell of my ballpoint pen securely in position, I confronted Soames’s housemates for a full history of the incident. “He was getting dressed, Miss,” explained Ponting, “It’s prize day, you see, and he wanted to look his best for the Admiral.”

    “He’s a very punctilious dresser, Doctor,” added Smithers, the housemaster. “We do tend to encourage the younger boys to pull hard on the knot to get the tie as high up the neck as possible. Presentation of self is a core value of the school.”

    “Good grief,” I retorted. “Haven’t you seen the latest health and safety guidance? Look, Mr Smithers, I’m giving you doctor’s orders. I want every boy in this school issued with a government model clip-on tie. I’ll be back this time next week to inspect them.”

    Smithers crept away shamefully, muttering something about lowering of standards. But I had the protection of my practice population to think about. I penned my case study—“Evidence supporting immediate abolition of the traditional school tie”—and sent it to Cases, requesting a fast track editorial process on the grounds of an impending public health emergency.

    The referees’ comments were returned to me within 48 hours. Splendid piece, they said, and Dr Smith likes the picture, but he’s asked you to calculate a number needed to harm. I pulled down my lecture notes on clinical epidemiology and set to work on the back of an envelope. Let’s think. The denominator would be every schoolboy (and a fair few schoolgirls) since records began—say a hundred million, give or take a score. The numerator was Soames.

    Smith was unimpressed. He put my article in the slow track for publication, along with a report on life threatening frontal lobe injury from stray conker and probable sighting of Elvis on moon.


    Cite this as: BMJ 2009;338:b2047

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